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HomeMy WebLinkAbout2024-00058495 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 010 III )III IIII lull 11111111IllIllHl 101 1111 0111 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003555515 u, 1 U2 1 1 1 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 5 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00058495 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT S RANDALL RD ® ❑ Elgin RELATED ❑Y CON 09 12 2024 08:43 EH,'" ❑YES ®No u1 -< PRIVATE mo /day/yr ®PM FLOW CONDITION m ONO 'COUNTY PROPERTY ElY ®N DOORING ❑Y #OF MOTOR ❑SLOW 2 f/) /MI N E CI W South St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O tg oRNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑Nav ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGED AREA(S) fi20 1T TOWED Ut O NAME(LAST,FIRST,M) . P. 0 mo 1 / day yr J 1 9 9 9 Ford Transit Connect 2018 00-NONE 11 01 , DUE TO CRASH El - 3 13-UNDERCARRIAGE •10I• I 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 2 m 30 S RADDANT RD M ❑Y ®SYSNEM DUNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 76-TOP 3 ,OSIractlonValue 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 I� 6 1 4 COM VEH 0 ® 1 0 R 1 FTBW3XM2JKB56614 Pekin Insurance Co ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 SHC Enterprises LLC 006382436 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 7316 TECKLER BLVD.Crystal Lake , IL.601014 (773)447-6819 VEHU GI ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 • GI m / J FOR DAMAGED AREA(S) FRONT TOWED �Y N s Rasmussen, Ralph, E. 0 9 0 2 1 9 5 3 Ford F150 2007 00-NONE tt. i'_t DUE TO CRASH Id 0 2 —I , NAME(LAST,FIRST,M) p mo day yr ©, 73 v t3-UNDER CARRIAGE 10, fj 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPDR C) SYSTEM IN 0 ENGAGED Q 15-OTHER 9 16-TOP 3 9 0 X a` 100 PATRICK DR M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN • •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & 1 iS.4 COM VEH ❑ ® U1 C FIRST CONTACT 6 7_(I_Q;_S •It Yes,See Sidebar to Z SOUTH ELGIN IL 60177 0 RAZ1-DD IL 2024 0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)212-3649 R252-7255-3250 IL D 0 1FTPW14V77KC93578 Bristol West Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same G01298834802 Bnc , 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YOND N Same U1 _ (UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m /• - #OCCS ' D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 91 /21 /024 08 43 ®pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 2 0 06 03 91 /21 /024 08 43 l81 PM ❑Construction * r�•A T 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 ® 11 1 ARREST NAME OBrien. Daniel. P. 11-601 388-001919 91 /21 /024 08 51 ®PM SLMT o U CITATIONS ISSUED 0 PENDING • ROAD CLEARANCE TIME 0 Utility SECTION CITATION NO. o N AM 50 I 2 ID1 1 1 ARREST NAME 91 /21 /024 09 15 El pm0 Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 388-Nelis. Ryan 801 - 10 / 81 /024 09 00 p PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I 1 INDICATE NORTH combination) or —I XI °i +.MM. I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` } i J. d i -` ` r r r (example.shuttle or charter bus)-or X I gOpgr l 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 ---' . ; i i 9 P by } } } transporting employees in the course of their employment(example employee M transporter-usually a van type vehicle or passenger car).or w , : i r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I : for direct compensation(example:large van used for specific purpose).or , y } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example-placards will be displayed on the vehicle) : " ' ; CARRIER NAME Z - e ADDRESS D '• a• s • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No : MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Blue.Light Black u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE